This is a blog by a former CEO of a large Boston hospital to share thoughts about hospitals, medicine, and health care issues.

Friday, September 09, 2011

Sad news from Dallas

One can only view this report with sadness: The Dallas Morning Newshas posted a story saying the CMS has threatened to shut off federal reimbursements for Parkland Memorial Hospital “because of deficiencies that represent an immediate and serious threat to patient health and safety."

The largest previous case like this was in 2006 when the King/Drew center in Los Angeles was informed that CMS would no longer pay for patient care there ($200 million per year in revenue, or more than half its budget). It was then closed. I cannot recall any other major medical center facing this kind of sanction.

There is, however, an out to avoid a September 30 deadline:

David Wright, acting deputy regional director for CMS, told The Dallas Morning News that Parkland could avert that funding cutoff if it entered into a “systems improvement agreement,” an arrangement in which the hospital would accept CMS-approved outside consultants. CMS said that Parkland had responded “favorably” to the idea, and it would be discussed next week.

I have previously written about the situation at Parkland Memorial. It is sad that a place so indelibly etched in the minds of those of us who were so impressed by the hospital's professionalism at the time of President Kennedy's assassination may now leave an altogether different impression.

I wonder to what extent the patient safety issues at Parkland relate to inadequate staffing ratios, high employee turnover and large numbers of still inexperienced employees. It wouldn’t be surprising if Parkland’s revenues are extremely stressed by a significant and growing uncompensated care burden as well as more that its share of low reimbursing Medicaid patients. It would be interesting to compare Parkland’s infection rates and other patient safety and outcomes metrics to other large safety net hospitals around the country facing similar financial pressure.

That all said, if the problems at Parkland are mainly the result of poor leadership and the inability to learn from mistakes and improve systems, then CMS’ threat to disqualify Parkland from treating Medicare patients is appropriate and an apparently necessary catalyst to bring about positive change.

Paul, CMS didn't threaten them with termination of participation: they terminated them, effective September 30th. The "out" is that if they negotiate an oversight agreement by Thursday, the Feds will go month to month with them. The CMS component of their budget is not $200 million, it's $430 million, or 55% of their revenue.

Beverly, it's not due to uncompensated care. The county pays them for that so abundantly that they bare one of the most profitable hospitals in Texas. Their profit last year was $110,000,000.00.

Texas is an odd (fascinating, often alarming) mix of international frontier, Western independence, and southern honor system. For every Rick Perry, there is a Barbara Jordan and Molly Ivins. Or was. Its hospitals, and attendant lack of a healthcare system, are an exemplar of the diverse extremes found in U.S. medicine. There are simultaneous races to the top of technology and science, and to the bottom of population skills and education. Well-heeled universities produce stellar scientists but poor counties can barely find science teachers.

Parkland, while clearly at fault, is also product of its downtrodden status as hospital of the poor, in a wealthy state where being poor means you are stupid or lazy or both. Texas seemed to be in a perpetual post WWII boom, but now population pressure and political retrograde are coming to roost in any measure of population health or care delivery. But as George Bush said in 2007, "People have access to health care in America. After all, you just go to an emergency room."

I suspect the correlation may hold: states and communities with better primary community health access have higher rated safety in tertiary hospital environments. It all comes down to competing for the wrong prize, and national leadership is fully culpable. Until the feds reward states for healthy populations, the most technologically advanced hospital can put safety lower on the spreadsheet - because safety requires a population view, rather than perpetuation of American rugged paternalism. (And it isn't just the doctor in the cowboy hat that doesn't wash his hands).

This mess lands squarely at the feet of UT-Southwestern and the leadership of the medical school. Parkland and UT Southwestern are indelibly linked and on the same campus. Children's Hospital of Dallas is the pediatric wing of Parkland. The school has not wanted to pay its physicians appropriately for the care at Parkland and wanted them to focus on their research. The result of this failure over many years was a culture where the entire hospital was run by medical students and training physicians. Students transport the patients to tests, draw blood, write orders which may or may not get cosigned, and every other critical function to care at Parkland. Attending physicians are only present in the facility from 830am to 1030am and for interesting surgeries only. The hospital leadership is okay with this situation because it keeps costs down. The nursing staff and janitorial staff do not perform their tasks because students will do them. Leadership is never known to actually walk the hallways. Elevators do not work, specimens get lost, and patients live and die on the level of care of the trainees who are responsible for them. It is a wonderful place to train because you do everything and see everything, but from an educational standpoint there is no systems based training there. It truly is the 9th pit of hell and moving to a new hospital will not change that.

Make no mistake, this is a political witch hunt. Having been a Parkland division chief for several years, I can tell you Parkland is one of the best run public hospitals in the US. Parkland is staffed by excellent physicians who are all UT Southwestern Medical School faculty.

See if any hospital can withstand the Federal government with its unlimited resources crawl up your a** with a microscope. They (the Feds) are going to find some germs!

Mike, I am afraid this attitude is what has landed your hospital into the mess that it is in. We have all had similar experiences with the feds and, as Paul notes, very few have had this outcome. Please do some soul searching.